- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,884.03 / $6,606.93
| Facility | | $1,288.25 | $2,884.03 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,884.03 / $4,570.88
| Professional | | $2,344.23 | $2,884.03 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $3,311.31 / $4,570.88
| Professional | | $1,778.28 | $3,311.31 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $3,019.95 / $5,888.44
| Facility | | $1,096.48 | $3,019.95 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,090.30 / $19,498.45
| Professional | | $2,398.83 | $3,090.30 | $19,498.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $1,949.84 / $6,165.95
| Facility | | $346.74 | $1,949.84 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,818.38 / $4,168.69
| Professional | | $2,187.76 | $2,818.38 | $4,168.69 |